Adult New Patient Health History Form Patient InformationPatient Full Name*Date of Birth Today's Date Previous Primary Care PhysicianReason for Today's VisitCurrent Medical HistoryHealth MaintenancePlease check if you've had any of the following: Colonoscopy Bone Density PAP Smear Mammogram Prostate Exam Eye Exam If you checked any of the above, please list the year performed below:Please check if you've had any of the following vaccines: Flu Tetanus Pneumonia Shingles If you checked any of the above, please list the year performed below:Prior Surgical HistoryPlease click the plus sign to the far right to add additional rows as needed.Type of SurgeryYear PerformedSurgeon Name Family HistoryPlease list any family history including the illness and reason for death.Social HistoryDo you drink?YesNoDo you use tobacco products?YesNoAny illicit drug use?YesNoDo you drink caffeine?YesNoWhat is your occupation?Do you use any of the following? CPAP Glucose strips Nebulizer Oxygen Walker Wheelchair Hospital bed Do you have routine transportation?YesNoCurrent PharmacyAllergiesList ALL medications including herbal remedies, vitamins, over-the-counter, street drugs and prescriptions. (Click the plus sign to the far right to add additional rows)MedicationDosage OB/GYN HistoryLast Menstrual PeriodDo you have irregular or heavy periods?YesNoHave you ever been pregnant?YesNoIf so, please list number of pregnancies and number of children.Do you have or have you ever had any of the following symptoms? (Check all that apply) Acid Reflux Anxiety/Depression Arthritis Asthma/COPD Bleeding Disorders Blood clots Blood in stool Blood in urine Breast abnormalities Changes in moles Constipation Diabetes Diarrhea Dizziness Headaches Hearing problems Heart problems Hepatitis High blood pressure HIV Joint Problems Lesions Liver problems Mood swings Nausea/vomiting Nipple discharge Problems urinating Rashes Seizures Sinus problems Sleep Apnea STD's Testicular pain Testicular swelling Thyroid problems Urinary tract infections Unplanned weight loss Vision problems If you answered yes to any of the above symptoms, please explain below:Please list any other conditions/illnesses not indicated above:To the best of my knowledge, this information is complete and correct. I understand that it is my responsibility to inform my healthcare provider if there are any changes in my health.